Anesthesia for patients with an anterior mediastinal mass
- Javier Lasala, MD
Javier Lasala, MD
- Assistant Professor
- The University of Texas MD Anderson Cancer Center
- Ron Purugganan, MD
Ron Purugganan, MD
- Professor of Anesthesiology and Perioperative Medicine
- Professor of Thoracic and Cardiovascular Surgery
- The University of Texas MD Anderson Cancer Center
Mediastinal masses may be small, slow-growing, and asymptomatic, or large, aggressive, symptomatic tumors (figure 1 and table 1). This topic discusses anesthetic care of patients undergoing a surgical procedure (eg, biopsy or resection) for diagnosis or treatment of an anterior mediastinal mass. Preanesthetic assessment, intraoperative anesthetic management, and early postoperative care are addressed.
Initial evaluation of mediastinal masses is discussed separately. (See "Approach to the adult patient with a mediastinal mass".)
The major goal of the preanesthesia consultation is to assess risk of airway or respiratory compromise and/or hemodynamic instability due to:
●Mass effect on the airway and lungs.
●Mass effect on major cardiovascular structures and circulation.
- Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol 2007; 20:1.
- Rath L, Gullahorn G, Connolly N, et al. Anterior mediastinal mass biopsy and resection: anesthetic techniques and perioperative concerns. Semin Cardiothorac Vasc Anesth 2012; 16:235.
- Torchio R, Gulotta C, Perboni A, et al. Orthopnea and tidal expiratory flow limitation in patients with euthyroid goiter. Chest 2003; 124:133.
- Hnatiuk OW, Corcoran PC, Sierra A. Spirometry in surgery for anterior mediastinal masses. Chest 2001; 120:1152.
- Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg 2006; 82:1185.
- Park BJ, Flores R, Downey RJ, et al. Management of major hemorrhage during mediastinoscopy. J Thorac Cardiovasc Surg 2003; 126:726.
- Vallières E, Pagé A, Verdant A. Ambulatory mediastinoscopy and anterior mediastinotomy. Ann Thorac Surg 1991; 52:1122.
- Nechala P, Graham AJ, McFadden SD, et al. Retrospective analysis of the clinical performance of anterior mediastinotomy. Ann Thorac Surg 2006; 82:2004.
- Roberts JR, Wadsworth J. Recurrent laryngeal nerve monitoring during mediastinoscopy: predictors of injury. Ann Thorac Surg 2007; 83:388.
- Benouaich V, Marcheix B, Carfagna L, et al. Anatomical bases of left recurrent nerve lesions during mediastinoscopy. Surg Radiol Anat 2009; 31:295.
- Rau B, Hünerbein M, Below C, Schlag PM. Video-assisted thoracic surgery. Staging and management of thoracic tumors. Surg Endosc 1998; 12:133.
- Visser WA, Liem TH, van Egmond J, Gielen MJ. Extension of sensory blockade after thoracic epidural administration of a test dose of lidocaine at three different levels. Anesth Analg 1998; 86:332.
- Gothard JW. Anesthetic considerations for patients with anterior mediastinal masses. Anesthesiol Clin 2008; 26:305.
- Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 2002; 121:2000.
- Gunn SR, Pinsky MR. Implications of arterial pressure variation in patients in the intensive care unit. Curr Opin Crit Care 2001; 7:212.
- Bendjelid K, Romand JA. Fluid responsiveness in mechanically ventilated patients: a review of indices used in intensive care. Intensive Care Med 2003; 29:352.
- Magder S. Clinical usefulness of respiratory variations in arterial pressure. Am J Respir Crit Care Med 2004; 169:151.
- Kramer A, Zygun D, Hawes H, et al. Pulse pressure variation predicts fluid responsiveness following coronary artery bypass surgery. Chest 2004; 126:1563.
- Renner J, Scholz J, Bein B. Monitoring fluid therapy. Best Pract Res Clin Anaesthesiol 2009; 23:159.
- Pinsky MR, Teboul JL. Assessment of indices of preload and volume responsiveness. Curr Opin Crit Care 2005; 11:235.
- Thiele RH, Colquhoun DA, Blum FE, Durieux ME. The ability of anesthesia providers to visually estimate systolic pressure variability using the "eyeball" technique. Anesth Analg 2012; 115:176.
- Mark JB. Central venous pressure monitoring: clinical insights beyond the numbers. J Cardiothorac Vasc Anesth 1991; 5:163.
- Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172.
- Jamshidi R, Weitzel N, Grocott HP, et al. Mediastinal mass with superior vena cava syndrome. Semin Cardiothorac Vasc Anesth 2011; 15:105.
- Yang YL, Lu HI, Huang HW, Tseng CC. Mediastinal tumor resection under the guidance of transoesophageal echocardiography. Anaesth Intensive Care 2007; 35:312.
- Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278.
- Sendasgupta C, Sengupta G, Ghosh K, et al. Femoro-femoral cardiopulmonary bypass for the resection of an anterior mediastinal mass. Indian J Anaesth 2010; 54:565.
- PREANESTHETIC ASSESSMENT
- Focused history and examination
- Preoperative tests and interventions
- CONSIDERATIONS FOR SPECIFIC SURGICAL PROCEDURES
- Minimally invasive approaches
- - Cervical mediastinoscopy and anterior mediastinotomy (Chamberlain procedure)
- - Thoracoscopy
- Open approaches (thoracotomy, sternotomy, thoracosternotomy)
- ANESTHETIC PREPARATION AND MANAGEMENT
- Vascular access
- Blood availability
- Planned epidural analgesia
- Induction of anesthesia
- Airway management
- - Preparation for airway control
- - Airway management during induction
- - Airway management during maintenance
- Hemodynamic management
- - Hemodynamic monitoring
- Intraarterial catheter
- Central venous catheter
- Other monitoring modalities
- - Hemodynamic management during induction
- - Hemodynamic management during maintenance
- - Planned cardiopulmonary bypass
- Emergence and extubation
- POSTANESTHETIC MANAGEMENT
- Emergency complications
- Pain management
- SUMMARY AND RECOMMENDATIONS